Clinical

Chronic management

Viral Hepatitis

Background

The prevalence of hepatitis C is estimated at 250 – 350,000 persons in UK and hepatitis B at 325,000 persons At least 70% of these individuals will be asymptomatic The significant increase in HBV is contributed to the immigration from high endemic areas like Eastern Europe and Africa in the past 5 years The Health Protection Agency predicts a doubling in the number of HCV cirrhosis between 2005 and 2015 An increase in decompensated liver disease and hepatocellular carcinoma

Patient View

  • Stigmatism of disease

Current Practice

Medical treatment HCV is combination antiviral therapy with pegylated interferon and ribavirin for 24 weeks or 48 weeks determined by genotype, viral kinetics and IL28 status. NICE HCV Tech Appraisal 75 and 106 Medical treatment HBV, pegylated interferon or oral antivirals Tenofovir or Entecavir, NICE HBV Tech Appraisal 75

Recommended Practice and Opportunities for Integrated Working

  • Commissioners should require that all migrants from countries where there is a prevalence of HBV or HCV > 2% should screened for blood-borne viruses (BBV)
  • All patients with asymptomatic abnormal LFTs should be screened for HBV and HCV
  • Targeted case finding within high risk populations ie IVDUs (past and present), prisoners
  • HBV vaccination should be available for prisoners and high risk groups
  • Patients on treatment for HBV and HCV failing to respond to best practice should have rapid access (by telephone/email/referral) to regional / supraregional specialist centres

Opportunities for Savings

  • Screening and case finding allows early treatment where indicated, reducing the risk of progression to end stage disease with its complications of portal hypertension, hepatocellular carcinoma and potential liver transplantation
  • Vaccination for HBV

Quality Indicators (Outcomes)

  • Application of screening tests in primary care
  • Rapid referral of positive cases
  • Patient satisfaction (that their illness is being taken seriously and treatment being offered or considered)
  • Treatment outcome measures in secondary care (ie % HCV patients who achieve SVR, > 40% GT 1 and > 70% GT 2/3), % patients HBV who have HBeAg seroconvertion or undetectable virus (HBVDNA < 20 IU/mL)

Social Policy & Understanding

  • Provision and improved access to screening and vaccination
  • Public health education by approved sources (government/charities) to advise general public, patients, medical practioners and all health care workers about;
    • The nature of the disease
    • The risks
    • When to see their doctor
    • Lifestyle issues
    • The treatments available, side effects

References